Traditionally, therapy has not played a big role in working with persons with dementia.
Often therapies such as occupational therapy, physical therapy, and speech therapy were not considered viable services due to the person with dementia’s limited ability to learn. For a long time, therapy was denied Medicare reimbursement based on a “no improvement” standard from the Medicare intermediaries.
However, this has been
addressed through litigation, and therapy has been recognized as a necessary and reimbursable service for persons with dementia. (
Jimmo vs. Sebelius, 2013.)
Currently there are approximately
5.4 million Americans living with Alzheimer’s disease.
By 2050, an estimated 13.8 million Americans ages 65 and older will have Alzheimer’s disease, the most common dementia, creating an enormous public health burden due to disability and dependence. (Rand Rapport—
Improving Dementia in Long-Term Care: A Policy Blueprint.)
There is a need for specialized and experienced therapists in this area of practice that parallels the increasing number of people diagnosed annually with the disease. Persons with dementia are at significant risk for falls, decline in function or excess disability, communication deficits, and stress reactions (behaviors) that impact function. Therapists have a vital role in addressing these issues.
In the home health setting, a strong interdisciplinary team approach is vital. Dementia care requires a team trained in treating persons with dementia and an effective and sustainable communication system within the team.
In order to provide the best care, every team member should have an ability to screen for:
Therapists need an in-depth understanding of the levels and assessments in order to develop goals and maintenance programs and create the best outcomes for the person with dementia and the care partner.
The Medicare Benefits Policy Manual, Chapter 7, specifically supports these therapy services through the use of a maintenance program:
Section 42.1 d. Assuming all other eligibility and coverage requirements have been met, in order for therapy services to be covered, one of the following three conditions must be met: . . . 2. The patient’s clinical condition requires the specialized skills, knowledge, and judgment of a qualified therapist to establish or design a maintenance program, related to the patient’s illness or injury, in order to ensure the safety of the patient and the effectiveness of the program, to the extent provided by regulation.
The manual further states:
Where there was no rehabilitative/restorative therapy program, and the specialized skills, knowledge, and judgment of a qualified therapist are required to develop a maintenance program, such services would be considered reasonable and necessary for the treatment of the patient’s condition in order to ensure the effectiveness of the treatment goals and ensure medical safety.
The instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a maintenance program is covered if the specialized skills, knowledge, and judgment of a qualified therapist are required.
How are maintenance programs used?
CMS states that maintenance programs are designed to maintain a person at their current level and to prevent or minimize further decline. (MBPM Chapter 15, section 220.2 D. Maintenance Programs.)
For therapists, this may be a paradigm shift. Therapists have long been providing
rehabilitation services, restoring patients to their prior level of functioning. With persons with dementia, we cannot fix the brain and facilitate their past functioning, but therapists can
habilitate.
“The aim of … habilitation therapy is not to restore people with a dementia such as Alzheimer’s disease to what they once were (i.e. rehabilitation), but to maximize independence and morale,” writes Paul Raia, Ph.D. in
Habilitation Therapy: A New Starscape [PDF]. “The primary learning task becomes how to value what is still there and not dwell on functions the person has lost.”
Photo: Pamela Moore/iStock
Habilitation is compensatory. We are not changing the person in therapy, we are changing the activity to match the person’s cognitive abilities, changing the environment to promote the person’s best abilities, and changing the care partner’s approach.
Habilitation requires a skilled therapist. It requires a skilled therapist to provide a comprehensive evaluation which includes the cognitive level of the patient, the person’s remaining abilities, and any risks that may be present due to the change in cognition.
Goals are established and a maintenance plan is created to facilitate the patient’s ability to perform daily tasks safely and at their best ability. Then the therapist teaches the care partner how to carry out the maintenance program.
Case study
I worked with a client who attended adult day care five days a week. He was cooperative in the day care environment, but had become more and more combative with his wife in the home and was very resistant to bathing and dressing, attempting to strike out at his wife.
Upon initial evaluation, I found he was performing at Allen Cognitive Level High 3. At the time of evaluation, his wife told me that she provided total care for all ADLs and that he demanded her constant attention throughout the evening and weekends. The caregiver expressed significant frustration and exhaustion; however, she stated that she did not want to place her husband in a memory care community.
On the OASIS (Outcome and Assessment Information Set) items for dressing and bathing, he scored at 3, indicating total dependence.
However, his Allen Cognitive Level score indicated
the cognitive ability to perform these tasks with setup and consistent cueing for accuracy and quality.
His wife was grateful to learn that he could assist with basic tasks. I created maintenance programs for basic ADLs and began teaching his wife compensatory techniques to facilitate his engagement in the activities.
During the treatment sessions, I discovered that he had enjoyed working with puzzles as a leisure activity. I brought a box of Legos (the box stated that Legos are for persons ages 9 to 99). He initially sat with the Legos for 45 minutes, sorting the objects by color and putting a few pieces together. His wife found she could use this activity with him every evening; he would feel productive and it gave her time to
take a breath and do things she needed to complete.
Upon discharge:
- The scores for bathing and dressing improved from dependent to requiring assistance.
- The score for frequency of behavior problems changed from 5 (at least daily) to 3 (several times each month).
- In addition, the caregiver expressed feeling less frustrated and more able to enjoy her time with her husband.
Additional home support
With these clients, the services of a social worker are essential to help discover any other community resources and support groups that may be available for the client and caregivers.
There is a significant need for dementia-capable healthcare professionals to assist the caregivers in their desire to keep their loved one in the home as long as possible. Therapy services can assist in creating plans and teaching care partners techniques to improve the patient’s function and safety. Most importantly, home care intervention can reduce the caregiver burden and improve the quality of life of the person with dementia and their care partner.
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